Provider Demographics
NPI:1922041508
Name:CORBACIO, EDWARD J (PT)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:CORBACIO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:82 TUNNEL RD
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3869
Mailing Address - Country:US
Mailing Address - Phone:570-622-5455
Mailing Address - Fax:570-622-5493
Practice Address - Street 1:495 N CLAUDE A LORD BLVD
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2705
Practice Address - Country:US
Practice Address - Phone:484-529-7470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006923L225100000X
PAPT006923-L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA049122Medicare PIN